306006280-6-4-2024-22-AS-RQUZ-D5WL7L-20240604083031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006280
Report Date: 06/03/2024
Date Signed: 06/04/2024 08:31:06 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/04/2024 08:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SHASTA RESIDENTIAL CARE		FACILITY NUMBER:	306006280
ADMINISTRATOR:	DINH, KEVIN DINO		FACILITY TYPE:	740
ADDRESS:	16274 SHASTA ST		TELEPHONE:	(714) 300-4540
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 5	DATE:	06/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Kevin Dinh, Licensee/Administrator		TIME COMPLETED:	01:20 PM

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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz made an unannounced visit on this day for the purpose of conducting an Annual Required-1 year inspection visit. LPA was greeted by Caregiver Thelma Asprec. LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Kevin Dinh and discussed purpose of today’s visit. (L/AD) Dinh arrived during today's visit.

The facility is a one story home which consists of: 3 shared resident bedrooms, 1 caregiver bedroom, 2 bathrooms designated for residents, 1 bathroom designated for visitors, residents and staff, living-room, kitchen with dining area, back yard with ample shade and outdoor furniture, garage with operational washer and dryer.

The facility is licensed for age range 60 and over, approved for capacity of 6 Non-Ambulatory residents, of which 1 may be bedridden and has a hospice waiver for 6 residents. Bedridden resident in Room #4 only. There is currently (1) one resident receiving hospice care services.

Administrator Kevin Dinh has a current Administrator's certificate which expires on 10/25/2024.

LPA along with L/AD Dinh toured the interior and exterior of facility. LPA observed kitchen for proper sanitation and cleanliness. LPA observed sharp objects locked and secured in cabinet in kitchen area, and observed toxin substances to be locked and inaccessible to residents in care in locked and secured closet in garage area. The food was observed to meet the minimum requirement of two days perishable and seven days nonperishable food supply for residents in care.

Resident bedroom areas were observed to have required furnishings including but not limited to: lamp, bed, mattress, night stand and clean linen. LPA interacted and interviewed 5 of 5 residents during facility tour. The water temperature in resident bathrooms were measured to be within 110.0- 112.8 degrees Fahrenheit. The Grab bars and non-slip mats were observed in resident bathrooms and shower room. Room temperature inside the facility was recorded to be 71 degrees F. CONTINUED NEXT LIC 809-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHASTA RESIDENTIAL CARE	FACILITY NUMBER: 306006280
	VISIT DATE: 06/03/2024

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CONTINUED... The outside grounds were inspected during facility tour, and no bodies of water were observed. No pool available at this facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPAs observed and tested functional and operational carbon monoxide and smoke alarms.

(L/AD) Dinh reports fire drills are conducted quarterly with staff and residents. Last facility fire drill was conducted on 3/25/2024.

LPA Quiroz reviewed whether the facility is operating within capacity limitations and reviewed repeated violations, no repeated violations assessed.

During today's visit, LPAs reviewed five of five resident records, centrally stored medications and four personnel files. Resident and personnel files were found to be within Title 22 California Code of Regulations.

Based on the observations made during today’s visit; there are no deficiencies being cited per Title 22 Division 6 of the California Code of Regulations. This report was read and reviewed with L/AD Dinh, and a copy of this report, LIC 858s, LIC 859 were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC809 (FAS) - (06/04)

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